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Perkins B, Huckleberry Y, Bogdanich I, Leelathanalerk A, Huckleberry A, Konecnik M, Miller DC, Bailey M, Bime C. Evaluation of Inpatient Opioid Prescribing Resulting in Outpatient Opioid Prescriptions for Previously Opioid-Naive Internal Medicine Patients. J Pharm Pract 2020; 35:179-183. [PMID: 33000671 DOI: 10.1177/0897190020961290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little data exist regarding inpatient opioid prescriptions as a potential contribution to the current opioid crisis. While pain management is essential to inpatient care, the ease of which opioids may be prescribed for all levels of pain may contribute to unnecessary inpatient exposure and new outpatient prescriptions. The aim of this study was to observe patterns of opioid prescribing potentially leading to new opioid prescriptions at hospital discharge for previously opioid-naive patients. METHODS This study was a single-center observational study of opioid-naïve internal medicine patients who were prescribed inpatient opioids. Patient charts were reviewed to assess the patterns of inpatient opioid and non-opioid analgesic use, new opioid prescriptions upon discharge and medical record documentation justifying the need for outpatient therapy. RESULTS Among the 101 patients included in this study, 71 were prescribed IV opioids and 45 were prescribed both IV and oral opioids. Non-opioid analgesics were available for 78 patients. Twenty patients were discharged with a new prescription. The mean duration of outpatient prescriptions was 3.85 +/- 1.85 days with mean morphine milligram equivalents (MME) of 44.25 +/- 22.16. Among patients receiving these outpatient prescriptions, 11 had reference to the therapy in the discharge summary. CONCLUSIONS This observational study describes an opportunity to improve inpatient opioid prescribing practices which may reduce new prescriptions for continued outpatient therapy. Further work should focus on optimizing use of non-opioid analgesia, minimizing use of IV opioids and requiring prescribers to justify the indication for new opioid prescriptions upon hospital discharge.
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Affiliation(s)
- Bryce Perkins
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Yvonne Huckleberry
- Banner University Medical Center, Tucson, AZ, USA.,College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Ivana Bogdanich
- Banner University Medical Center, Tucson, AZ, USA.,College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Areerut Leelathanalerk
- Banner University Medical Center, Tucson, AZ, USA.,College of Pharmacy, University of Arizona, Tucson, AZ, USA.,Mahasarakham University, Maha Sarakham, Thailand
| | | | - Michaela Konecnik
- Banner University Medical Center, Tucson, AZ, USA.,College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - David C Miller
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Morgan Bailey
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Christian Bime
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA
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Bai Y, Sun K, Xing X, Zhang F, Sun N, Gao Y, Zhu L, Yao J, Fan J, Yan M. Postoperative analgesic effect of hydromorphone in patients undergoing single-port video-assisted thoracoscopic surgery: a randomized controlled trial. J Pain Res 2019; 12:1091-1101. [PMID: 31114295 PMCID: PMC6497863 DOI: 10.2147/jpr.s194541] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022] Open
Abstract
Objective: To study the general efficacy of hydromorphone as a systemic analgesic in postoperative pain management following single-port video-assisted thoracoscopic surgery (VATS) and to explore the optimal administration regimen. Methods: A prospective, randomized, double-blind study was designed and conducted in a tertiary hospital. In total, 157 valid patients undergoing single-port VATS were randomly allocated into three groups. A total of 53 patients received morphine bolus only for postoperative analgesia (Group Mb); 51 patients received a hydromorphone background infusion plus bolus (Group Hb + i), and 53 patients received a hydromorphone bolus only (Group Hb). The primary outcomes were patient-reported static and dynamic pain levels; the secondary outcomes included side effects, sleep quality, and recovery indexes. Results: Patients in Group Hb + i experienced lower pain intensity (approximately 10 out of 100 on the visual analog scale) in both static pain and dynamic pain in the days following surgery (P<0.01), better sleep quality during the first night only (P=0.002), and a higher satisfaction level than those in the other two groups (P=0.006). A comparison of these variables in Group Mb and Group Hb resulted in no significant differences. Lastly, side effects and recovery indexes remained the same among bolus-only groups and bolus-plus-background-infusion groups. Conclusion: There is no advantage to administering hydromorphone over morphine using bolus only mode. Within 24 h after surgery, a background infusion should be considered as a part of a standard protocol for patient-controlled intravenous analgesia. At 24 h after surgery, the background infusion should be adjusted in accordance with patient preferences and pain intensity.
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Affiliation(s)
- Yongyu Bai
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Kai Sun
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Xiufang Xing
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Fengjiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Na Sun
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou 221004, People's Republic of China
| | - Yibo Gao
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Ling Zhu
- Department of Thoracic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Jie Yao
- Department of Thoracic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Junqiang Fan
- Department of Thoracic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People's Republic of China
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Lemoine A, Lambaudie E, Bonnet F, Leblanc E, Alfonsi P. [Perioperative care of epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:187-196. [PMID: 30686730 DOI: 10.1016/j.gofs.2018.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 01/28/2023]
Abstract
The following recommendations cover the perioperative management of ovarian, Fallopian tube and primary peritoneal cancers. Five questions related to pre-habilitation and enhanced recovery after surgery were evaluated. The conclusions and recommendations are based on an analysis of the level of evidence available in the literature. These recommendations are part of the overall recommendations for improving the management of ovarian, fallopian or primary peritoneal cancer, made with the support of INCa (Institut National du Cancer). The main preoperative measures are screening for nutritional deficiencies (Grade B) and for anaemia (GradeC) in patients with ovarian cancer. It is not possible to make recommendations on the correction of malnutrition and/or anemia or on the contribution of pre-operative immuno-nutrition due to the absence of data in ovarian cancer, tube cancer or primary peritoneum cancer. For the same reasons, no recommendation can be made on the value of preoperative digestive preparation in ovarian, fallopian tube or primary peritoneum cancer. During surgery, goal-directed fluid therapy for patients with advanced ovarian cancer is recommended (Grade B). A single dose infusion of tranexamic acid is recommended for patients with ovarian, fallopian tube or primary peritoneal cancer (GradeC). For postoperative analgesia, epidural analgesia is recommended for patients undergoing cyto-reduction surgery by laparotomy (Grade B). In the absence of epidural analgesia, patient controlled analgesia with morphine without continuous infusion (Grade B) is recommended. No recommendation can be given regarding intravenous administration of lidocaine and/or ketamine during surgery, or, regarding peri-operatively prescription of gabapentin or pregabalin. In the absence of studies on the impact of different non-opiate analgesic combinations for ovarian cancer surgery, no recommendations can be made. Early oral feeding is recommended, including in cases of digestive resection (Grade B). The implementation of enhanced recovery programs, including early mobilization, is recommended (GradeC).
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Affiliation(s)
- A Lemoine
- Service d'anesthésie, hôpital Tenon, médecine Sorbonne université, 75020 Paris, France.
| | - E Lambaudie
- Inserm, département de chirurgie oncologique, institut Paoli Calmettes, Aix-Marseille université, CNRS, 13000 Marseille, France
| | - F Bonnet
- Service d'anesthésie, hôpital Tenon, médecine Sorbonne université, 75020 Paris, France
| | - E Leblanc
- Département de chirurgie oncologique, centre Oscar Lambret, 59000 Lille, France
| | - P Alfonsi
- Service d'anesthésie, université Paris Descartes, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France
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Ackerman AL, O'Connor PG, Doyle DL, Marranca SM, Haight CL, Day CE, Fogerty RL. Association of an Opioid Standard of Practice Intervention With Intravenous Opioid Exposure in Hospitalized Patients. JAMA Intern Med 2018; 178:759-763. [PMID: 29799964 PMCID: PMC6145746 DOI: 10.1001/jamainternmed.2018.1044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Opioids are commonly used to treat pain in hospitalized patients; however, intravenous administration carries an increased risk of adverse effects compared with oral administration. The subcutaneous route is an effective method of opioid delivery with favorable pharmacokinetics. OBJECTIVE To assess an intervention to reduce intravenous opioid use, total parenteral opioid exposure, and the rate of patients administered parenteral opioids. DESIGN, SETTING, AND PARTICIPANTS A pilot study was conducted in an adult general medical unit in an urban academic medical center. Attending physicians, nurse practitioners, and physician assistants who prescribed drugs were the participants. Use of opioids was compared between a 6-month control period and 3 months following education for the prescribers on opioid routes of administration. INTERVENTIONS Adoption of a local opioid standard of practice, preferring the oral and subcutaneous routes over intravenous administration, and education for prescribers and nursing staff on awareness of the subcutaneous route was implemented. MAIN OUTCOMES AND MEASURES The primary outcome was a reduction in intravenous doses administered per patient-day. Secondary measures included total parenteral and overall opioid doses per patient-day, parenteral and overall opioid exposure per patient-day, and daily rate of patients receiving parenteral opioids. Pain scores were measured on a standard 0- to 10-point Likert scale over the first 5 days of hospitalization. RESULTS The control period included 4500 patient-days, and the intervention period included 2459 patient-days. Of 127 patients in the intervention group, 59 (46.5%) were men; mean (SD) age was 57.6 (18.5) years. Intravenous opioid doses were reduced by 84% (0.06 vs 0.39 doses per patient-day, P < .001), and doses of all parenteral opioids were reduced by 55% (0.18 vs 0.39 doses per patient-day, P < .001). In addition, mean (SD) daily parenteral opioid exposure decreased by 49% (2.88 [0.72] vs 5.67 [1.14] morphine-milligram equivalents [MMEs] per patient-day). The daily rate of patients administered any parenteral opioid decreased by 57% (6% vs 14%; P < .001). Doses of opioids given by oral or parenteral route were reduced by 23% (0.73 vs 0.95 doses per patient-day, P = .02), and mean daily overall opioid exposure decreased by 31% (6.30 [4.12] vs 9.11 [7.34] MMEs per patient-day). For hospital days 1 through 3, there were no significant postintervention vs preintervention differences in mean reported pain score for patients receiving opioid therapy: day 1, -0.19 (95% CI, -0.94 to 0.56); day 2, -0.49 (95% CI, -1.01 to 0.03); and day 3, -0.54 (95% CI, -1.18 to 0.09). However, significant improvement was seen in the intervention group on days 4 (-1.07; 95% CI, -1.80 to -0.34) and 5 (-1.06; 95% CI, -1.84 to -0.27). CONCLUSIONS AND RELEVANCE An intervention targeting the use of intravenous opioids may be associated with reduced opioid exposure while providing effective pain control to hospitalized adults.
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Affiliation(s)
- Adam L Ackerman
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Hospitalist Service, Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Patrick G O'Connor
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Deirdre L Doyle
- Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Sheyla M Marranca
- Hospitalist Service, Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Carolyn L Haight
- Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Christine E Day
- Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Robert L Fogerty
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Hospitalist Service, Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
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McNicol ED, Ferguson MC, Hudcova J. Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain. Cochrane Database Syst Rev 2015; 2015:CD003348. [PMID: 26035341 PMCID: PMC7387354 DOI: 10.1002/14651858.cd003348.pub3] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne et al found a strong patient preference for PCA over non-patient controlled analgesia, but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, a 2001 review by Walder et al did not find statistically significant differences in pain intensity or pain relief between PCA and groups treated with non-patient controlled analgesia. OBJECTIVES To evaluate the efficacy and safety of patient controlled intravenous opioid analgesia (termed PCA in this review) versus non-patient controlled opioid analgesia of as-needed opioid analgesia for postoperative pain relief. SEARCH METHODS We ran the search for the previous review in November 2004. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 12), MEDLINE (1966 to 28 January 2015), and EMBASE (1980 to 28 January 2015) for randomized controlled trials (RCTs) in any language, and reference lists of reviews and retrieved articles. SELECTION CRITERIA We selected RCTs that assessed pain intensity as a primary or secondary outcome. These studies compared PCA without a continuous background infusion with non-patient controlled opioid analgesic regimens. We excluded studies that explicitly stated they involved patients with chronic pain. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. We performed meta-analysis of outcomes that included pain intensity assessed by a 0 to 100 visual analog scale (VAS), opioid consumption, patient satisfaction, length of stay, and adverse events. MAIN RESULTS Forty-nine studies with 1725 participants receiving PCA and 1687 participants assigned to a control group met the inclusion criteria. The original review included 55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group. There were fewer included studies in our updated review due to the revised exclusion criteria. For the primary outcome, participants receiving PCA had lower VAS pain intensity scores versus non-patient controlled analgesia over most time intervals, e.g., scores over 0 to 24 hours were nine points lower (95% confidence interval (CI) -13 to -5, moderate quality evidence) and over 0 to 48 hours were 10 points lower (95% CI -12 to -7, low quality evidence). Among the secondary outcomes, participants were more satisfied with PCA (81% versus 61%, P value = 0.002) and consumed higher amounts of opioids than controls (0 to 24 hours, 7 mg more of intravenous morphine equivalents, 95% CI 1 mg to 13 mg). Those receiving PCA had a higher incidence of pruritus (15% versus 8%, P value = 0.01) but had a similar incidence of other adverse events. There was no difference in the length of hospital stay. AUTHORS' CONCLUSIONS Since the last version of this review, we have found new studies providing additional information. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides moderate to low quality evidence that PCA is an efficacious alternative to non-patient controlled systemic analgesia for postoperative pain control.
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Affiliation(s)
- Ewan D McNicol
- Departments of Anesthesiology and Pharmacy, Tufts Medical Center, Box #420, 800 Washington Street, Boston, Massachusetts, USA, 02111
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Crisp CC, Bandi S, Kleeman SD, Oakley SH, Vaccaro CM, Estanol MV, Fellner AN, Pauls RN. Patient-controlled versus scheduled, nurse-administered analgesia following vaginal reconstructive surgery: a randomized trial. Am J Obstet Gynecol 2012; 207:433.e1-6. [PMID: 22863282 DOI: 10.1016/j.ajog.2012.06.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 05/21/2012] [Accepted: 06/18/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine whether patient-controlled analgesia or scheduled intravenous analgesia provides superior pain relief and satisfaction with pain control after vaginal reconstructive surgery. STUDY DESIGN Fifty-nine women scheduled for vaginal reconstructive surgery were enrolled in this randomized trial. Operative procedures and postoperative orders were standardized. Visual analog scales for pain and satisfaction with pain control were recorded during the hospital stay and 2 weeks after surgery. RESULTS Patients receiving patient-controlled analgesia had less pain on postoperative day 1, 25 mm vs 39 mm, on visual analog scales (P = .007). Although this group used twice as much hydromorphone (3.57 mg vs 1.48 mg, P < .001), there was no difference in side effects, length of hospital stay, or complications. For the sample overall, larger amounts of narcotic used correlated with higher pain scores (r = 0.364, P = .009) and worse satisfaction scores (r = -0.348, P = .012). CONCLUSION In patients undergoing vaginal surgery, patient-controlled analgesia offers superior pain relief on postoperative day 1 when compared with scheduled, nurse-administered hydromorphone.
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Dev R, Del Fabbro E, Bruera E. Patient-controlled analgesia in patients with advanced cancer. Should patients be in control? J Pain Symptom Manage 2011; 42:296-300. [PMID: 21444180 DOI: 10.1016/j.jpainsymman.2010.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 11/18/2010] [Accepted: 11/23/2010] [Indexed: 11/29/2022]
Abstract
Patient-controlled analgesia (PCA) has been incorporated into the management of chronic pain in cancer patients despite limited evidence of safety and efficacy. Potential benefits of PCA include decreased delay in the administration of opioids from the time requested, rapidity and ease of dose titration, and adaptability to the variable analgesic dosing needs, as well as diurnal changes in patients. PCA may be beneficial for the initial titration of opioids but has the potential to either induce or exacerbate delirium in cancer patients. Clinicians need to closely monitor for symptoms of delirium in advanced cancer patients. The following case presentation highlights the complication of delirium in a cancer patient who was prescribed PCA. Patients with advanced cancer are at increased risk for delirium, which is often difficult to predict.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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[Patient-controlled analgesia. Pain and Locoregional Anesthesia Committee and the Standards Committee of the French Society of Anesthesia and Intensive Care]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:e49-59. [PMID: 19186023 DOI: 10.1016/j.annfar.2008.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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